Crash of a Gippsland GA8 Airvan in the Buckingham Bay: 1 killed

Date & Time: Oct 16, 2008 at 0945 LT
Type of aircraft:
Registration:
VH-WRT
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Elcho Island – Mata Mata – Muthamul –Nyinyikay – Rurruwuy – Elcho Island
MSN:
GA8-01-005
YOM:
2001
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1300
Captain / Total hours on type:
300.00
Aircraft flight hours:
4750
Circumstances:
On the morning of 16 October 2008, a Gippsland Aeronautics GA8 Airvan, registered VH-WRT, was being operated on a freight charter flight from Elcho Island and return, Northern Territory. At about 1230, it was realised that the aircraft was missing. A witness reported seeing the aircraft during the early stages of the flight and, shortly afterwards, a column of dark black smoke rising from the eastern side of the Napier Peninsula. On 17 October 2008, items of wreckage from the aircraft were found in the south-western part of Buckingham Bay. The pilot, who was the sole occupant of the aircraft, and the main wreckage of the aircraft have not been found. After consideration of the available evidence, the investigation was unable to identify any factor that contributed to the accident.
Probable cause:
Following a review of the available evidence covering:
• Witness information,
• The pilot's fatigue and health,
• The airworthiness of the aircraft,
• Aircraft fuel,
• The weather affecting the flight, and
• The aircraft’s loading and weight and balance,
The investigation was unable to identify any factors that may have contributed to the accident. From the evidence available, the following findings are made with respect to the missing aircraft at Buckingham Bay, Northern Territory on 16 October 2008 involving Gippsland Aeronautics GA8 Airvan aircraft, registered VH-WRT. They should not be read as apportioning blame or liability to any organisation or individual. No contributing safety factors were identified.
Other safety factors:
• The main vertical net and the throwover net were not used to restrain the cargo.
• The full jerry cans were not secured in the aircraft cabin.
• At the time of departure, the aircraft’s centre of gravity (c.g) was probably to the rear of the permitted c.g limit that was published in the Aircraft Flight Manual.
• There was no record that the pilot lodged a flight notification for the flight with Airservices Australia.
Final Report:

Crash of a De Havilland DHC-5D Buffalo in Lokichoggio

Date & Time: Sep 29, 2008
Type of aircraft:
Registration:
5Y-OPL
Flight Type:
Survivors:
Yes
MSN:
84
YOM:
1978
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Upon landing at Lokichoggio Airport, the airplane banked right, causing the right propeller and the right wing to struck the runway surface. The aircraft slid for few dozen metres before coming to rest. There were no injuries while the aircraft was damaged beyond repair.
Probable cause:
It is believed that the right main gear was stuck in its wheel well because the door was blocked.

Crash of a Convair CV-580 in Columbus: 3 killed

Date & Time: Sep 1, 2008 at 1206 LT
Type of aircraft:
Operator:
Registration:
N587X
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Columbus - Mansfield
MSN:
361
YOM:
1956
Flight number:
HMA587
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
16087
Copilot / Total flying hours:
19285
Aircraft flight hours:
71965
Circumstances:
The accident flight was the first flight following maintenance that included flight control cable rigging. The flight was also intended to provide cockpit familiarization for the first officer and the pilot observer, and as a training flight for the first officer. About one minute after takeoff, the first officer contacted the tower and stated that they needed to return to land. The airplane impacted a cornfield about one mile southwest of the approach end of the runway, and 2 minutes 40 seconds after the initiation of the takeoff roll. The cockpit voice recorder (CVR) indicated that, during the flight, neither the captain nor the first officer called for the landing gear to be raised, the flaps to be retracted, or the power levers to be reduced from full power. From the time the first officer called "rotate" until the impact, the captain repeated the word "pull" about 27 times. When the observer pilot asked, "Come back on the trim?" the captain responded, "There's nothing anymore on the trim." The inspection of the airplane revealed that the elevator trim cables were rigged improperly, which resulted in the trim cables being reversed. As a result, when the pilot applied nose-up trim, the elevator trim system actually applied nose-down trim. The flight crew was briefed on the maintenance work that had been performed on the airplane; therefore, when the captain’s nose-up trim inputs were affecting his ability to control the airplane, at a minimum, he should have stopped making additional inputs and returned the airplane to the configuration it was in before the problem worsened. An examination of the maintenance instruction cards used to conduct the last inspection revealed that the inspector's block on numerous checks were not signed off by the Required Inspection Item (RII) inspector. The RII inspector did not sign the item that stated: "Connect elevator servo trim tab cables and rig in accordance with Allison Convair [maintenance manual]...” The item had been signed off by the mechanic, but not by the RII inspector. The card also contained a NOTE, which stated in bold type, "A complete inspection of all elevator controls must be accomplished and signed off by an RII qualified inspector and a logbook entry made to this effect." The RII inspector block was not signed off.
Probable cause:
The improper (reverse) rigging of the elevator trim cables by company maintenance personnel, and their subsequent failure to discover the misrigging during required post-maintenance checks. Contributing to the accident was the captain’s inadequate post-maintenance preflight check and the flight crew’s improper response to the trim problem.
Final Report:

Crash of a Fokker F27 Friendship 500 in K50: 3 killed

Date & Time: Aug 13, 2008 at 0450 LT
Type of aircraft:
Operator:
Registration:
5Y-BVF
Flight Type:
Survivors:
No
Schedule:
Nairobi – K50
MSN:
10627
YOM:
1982
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
The aircraft departed Nairobi-Jomo Kenyatta Airport on a cargo flight to the K50 Airstrip located about 35 km southwest of Mogadishu, carrying three crew members and a load of 5,4 tons of khat. On approach by night, the crew was unable to establish a visual contact with the runway due to foggy conditions. The captain initiated a go-around and the crew attempted a second approach to land. Too low, the airplane collided with a 60 metres high communication antenna and crashed 2 km from the airport. All three occupants were killed.

Crash of a Pilatus PC-6/B2-H4 Turbo Porter near Ndundu: 1 killed

Date & Time: Aug 9, 2008 at 2000 LT
Operator:
Registration:
PK-RCZ
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Wamena - Ndundu
MSN:
903
YOM:
1994
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
4624
Captain / Total hours on type:
2275.00
Aircraft flight hours:
6321
Circumstances:
On the Saturday 9 August 2008, a Pilatus Porter PC-6 B2-H4 aircraft, registered PK-RCZ, operated by AMA (Association of Mission Aviation) on a charter flight from Wamena, Papua, to Taive II, Papua departed at 1000 UTC. The aircraft was to pick up a medical patient from Taive II. After landing and unloading cargo at Taive II, the aircraft departed from Taive II for NduNdu, Papua, at 1106 with an estimated time of arrival of 1113. The flight was to be operated in accordance with the visual flight rules (VFR), remaining clear of cloud and navigating visually. When the aircraft had not arrived by 1213, the Wamena authorities decided to search for the aircraft. Three operators assisted the search; Association of Mission Aviation (AMA), Mission Aviation Fellowship (MAF), and Yajasi. They all reported hearing PK-RCZ’s emergency locator transmitter (ELT) signal, but were unable to reach the crash site due to the weather conditions. At 2020 (0520 local time on Sunday 10 August), the aircraft wreckage was found at an elevation of 6,400 feet at the coordinates 03° 26’ 08” S, 138° 21’ 58” E, in the area of NduNdu Pass, on the aircraft’s planned track. The crash site was about 200 feet to the left (east) of the southerly track across the Pass, on the slope of an 11,000 foot mountain. The coordinates and elevation of the lowest point in the NduNdu Pass were
03° 26’ 26” S, 138° 21’ 22” E and 5,700 feet. The pilot, the sole occupant, was fatally injured.
Probable cause:
The pilot continued the flight into cloud and did not initiate action to maintain visual flight conditions. The sector of the flight across the mountain pass was not conducted in conformance with the visual flight rules, and the pilot was did ensure that the aircraft remained clear of the terrain.
Final Report:

Crash of a Boeing 747-209BSF in Bogotá: 2 killed

Date & Time: Jul 7, 2008 at 0352 LT
Type of aircraft:
Operator:
Registration:
N714CK
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Bogotá – Miami
MSN:
22446/519
YOM:
1981
Country:
Crew on board:
8
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
8874
Captain / Total hours on type:
2874.00
Copilot / Total flying hours:
11373
Copilot / Total hours on type:
2853
Aircraft flight hours:
90613
Circumstances:
Shortly after take off from Bogotá-El Dorado Airport, while climbing by night, the crew informed ATC about engine problems and was cleared for an immediate return. After the crew realized he could not make it, he attempted an emergency landing when the aircraft collided with a farm and crashed in an open field. While all 8 crew members were injured (five seriously), two people in the farm were killed. The aircraft was totally destroyed by impact forces.
Probable cause:
The inability of the accident aircraft to maintain flight after the loss of power of two engines.
The following contributing factors were identified:
A non-recoverable surge on the engine n°4 during the rotation, resulting in a loss of engine power. Contributing to the surge were the combined effects of the inefficient high pressure turbine, excessive blade-tip clearance, reduced cord of the fan blades and of the leading edges and the effects of high altitude. An undetermined anomaly in the engine n°1, which manifested itself during the extra power, resulted in loss of engine power. Contributing to the loss of engine power was inadequate n°1 operation to maintain the proper speed during the ascent of the aircraft, resulting in extra power use and, in turn, exposing the anomaly of the engine.
Final Report:

Crash of a Douglas DC-9-15F in Saltillo: 1 killed

Date & Time: Jul 6, 2008 at 0113 LT
Type of aircraft:
Operator:
Registration:
N199US
Flight Type:
Survivors:
Yes
Schedule:
Hamilton – Shreveport – Saltillo
MSN:
47153/185
YOM:
1967
Flight number:
JUS199
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
7146
Captain / Total hours on type:
2587.00
Copilot / Total flying hours:
6842
Copilot / Total hours on type:
88
Aircraft flight hours:
54141
Aircraft flight cycles:
69161
Circumstances:
The aircraft departed Hamilton, Ontario, on a cargo flight to Saltillo, Coahuila, with an intermediate stop in Shreveport, LA, carrying two pilots and a load consisting of 4 tons of auto parts. The aircraft arrived in Shreveport at 2319LT and departed at 2348LT. On approach to Saltillo-Plan de Guadalupe Airport, the crew encountered low visibility due to poor weather conditions and dark night. On final approach to runway 17, as the captain was unable to establish a visual contact with the runway, he decided to abandon the approach and initiated a go-around procedure. Nine seconds later, the aircraft stuck the ground and crashed 550 metres to the east of the runway 17 threshold, bursting into flames. The aircraft was totally destroyed, the captain was killed and the copilot was seriously injured.
Probable cause:
The continuation of an unstable final approach without having the runway in sight and the consequent loss of control at low altitude in view of the imminent impact.
The following contributing factors were identified:
- Weather conditions at the airport,
- Unstabilized approach,
- Crew fatigue,
- Lack of experience of the copilot,
- Failure to follow proper procedures,
- Lack of operational procedures,
- Not following proper Saltillo tower controller procedures,
- Lack of supervision by the authority,
- The coincidence of factors that individually would not represent a substantial increase in the risk of the operations, but that in this case were added, that is; late night flight, little experience of the co-pilot, omission of briefing by the captain, a single Jeppesen for two pilots, DME #2 inoperative, captain command bars inoperative, DME arc, ILS/DME approach, omission of fog bank report and finally saturation in the communications with the Monterrey Control Center.
Final Report:

Crash of an Ilyushin II-76TD in Khartoum: 4 killed

Date & Time: Jun 30, 2008 at 0700 LT
Type of aircraft:
Operator:
Registration:
ST-WTB
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Khartoum – Juba
MSN:
10034 99994
YOM:
1990
Flight number:
BBE700
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
15634
Captain / Total hours on type:
4794.00
Circumstances:
The aircraft was cleared for takeoff and began its departure roll with flaps retracted, according to flight data recorder. The aircraft rotated at 280 kph (151 knots) and became airborne at 288 kph (155 knots) at an angle of attack of about 8-9 degrees. Tyre marks on the runway showed, that the aircraft had gone past the end of the runway, the main tyres had impacted runway end lights and the tyre tracks continued past the paved surface of the stopway. Climbing through 15 feet the pilot flying commanded the gear up and increased the pitch angle, the angle of attack increased to more than 10 degrees while the gear doors opened for gear retraction increasing the drag of the aircraft, which began to slow, the speed reduced to 305 kph (164 knots), stall speed for the takeoff weight, and the left wing began to stall, the angle of attack increased to 17 degrees, the aircraft at a height of 5-7 meters/15-23 feet. The pilot flying tried to counteract the roll to the left by fully applying left aileron which also deployed the right wing spoilers, right rudder input was provided. The pilot flying instructed the flight engineer to NOT retract flaps indicative neither pilot was aware the flaps were up. Following that instruction the flight engineer selected the flaps down, the aircraft speed was 300 kph (162 knots) and the aircraft in an unrecoverable stall with no height left. The left hand wing struck a high voltage mast about 1200 meters past the runway end at a height of 5.4 meters (18 feet) shearing off the left wing tip, contacted the flag post at the entrance of the Green Square, the left wing contacted the stem of a tree at a height of about 40 cm (1.3 feet) separating the ailerons and causing fuel spilling from the left wing, the aircraft broke through the eastern brick wall of Green Square, collided with two more electric poles causing engine #4 to separate 1504 meters from the end of the runway and impacted ground at 30 degrees nose down, 30 degrees left bank. Debris was distributed over a length of more than 500 meters, the aircraft burst into flames. All 4 crew perished in the crash, 4 people on the ground received serious, 3 more received minor injuries.
Probable cause:
The following findings were identified:
- From the CVR recording it appeared that no checklist had been used during all phases from engine start up, taxiing and take off,
- Ababeel company does not keep any records or files regarding the crew flying experience. They joined the company about four months before the accident,
- Engine n°1 showed only 96.2% N1 and thus delivered less thrust than the other three engines,
- Engine n°4 showed a 30° higher EGT than the other engines indicating that the engine was not in a satisfactory condition requiring the temperature limiter to be switched off to enable the engine to deliver the thrust needed,
- According to the FCOM the aircraft would need 2,850 meters takeoff distance at 188 tons takeoff weight with flaps at 30° and slats at 14°. As the crew did not use the checklists, either they were used to extend the flaps and slats after the aircraft gained certain speed and their attention was being drawn by monitoring the engine which the navigator asked about or another serious defect or they forgot to extend the flaps due to fatigue caused by alcohol consumption by the flight engineer and short periods of rest for the first officer. The clean aircraft lift off after rolling for a distance of 2,380 meters for take off which was a very short distance for such weight and temperature of 27°. Retracting of landing gear immediately within lift-off increased drag before the aircraft gained positive lift,
- the aircraft never climbed above 7 meters (23 feet) above ground,
- the aircraft had an automatic configuration warning which would activate at 70 +/- 15 kph, if the flaps were not extended. This system however could be switched off, or might have been malfunctioning, it did not activate during the takeoff run.

Ground fire of a Boeing 767-281SF in San Francisco

Date & Time: Jun 28, 2008 at 2218 LT
Type of aircraft:
Operator:
Registration:
N799AX
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
San Francisco – Wilmington
MSN:
23432/145
YOM:
1986
Flight number:
ABX1611
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On June 28, 2008, about 2215 Pacific daylight time, an ABX Air Boeing 767-200, N799AX, operating as flight 1611 from San Francisco International Airport, San Francisco, California, experienced a ground fire before engine startup. The captain and the first officer evacuated the airplane through the cockpit windows and were not injured, and the airplane was substantially damaged. The cargo flight was operating under the provisions of 14 Code of Federal Regulations Part 121. At the time of the fire, the airplane was parked near a loading facility, all of the cargo to be transported on the flight had been loaded, and the doors had been shut.
Probable cause:
The National Transportation Safety Board determines that the probable cause of this accident was the design of the supplemental oxygen system hoses and the lack of positive separation between electrical wiring and electrically conductive oxygen system components. The lack of positive separation allowed a short circuit to breach a combustible oxygen hose, release oxygen, and initiate a fire in the supernumerary compartment that rapidly spread to other areas. Contributing to this accident was the Federal Aviation Administration’s (FAA) failure to require the installation of nonconductive oxygen hoses after the safety issue concerning conductive hoses was initially identified by Boeing.
Final Report:

Crash of an Antonov AN-12BK near Malakal: 7 killed

Date & Time: Jun 27, 2008 at 0705 LT
Type of aircraft:
Operator:
Registration:
ST-ARN
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Khartoum – Juba
MSN:
8 3 460 10
YOM:
1968
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
7
Captain / Total flying hours:
13300
Captain / Total hours on type:
5000.00
Copilot / Total flying hours:
11535
Copilot / Total hours on type:
3300
Aircraft flight hours:
14597
Aircraft flight cycles:
6924
Circumstances:
The aircraft departed Khartoum at 0555LT on a cargo flight to Juba with 8 crew members on board. While cruising at FL170 in bad weather conditions, the engines n° 1 failed. One minute later, the engine n°3 failed as well, followed 40 seconds later by the failure of the engine n°4. The aircraft initiated a descent with a rate of 3,450 feet per minute and reach the altitude of 800 feet three minutes and 40 seconds after the failure of the engine n°1. At an altitude of 600 feet, the crew stabilized the aircraft and elected to restart the three engines but without success. Too low, the aircraft struck trees, lost its left stabilizer and crashed in a prairie 264 metres past the initial impact, bursting into flames. A crew member was rescued while 7 other occupants were killed.
Probable cause:
Loss of control and subsequent ground impact following the failure of engine n°1, 3 and 4.
The following contributing factors were identified:
- The crew entered an area of thunderstorm activity with turbulences and icing conditions,
- Unserviceability or sudden failure of the weather radar,
- Accumulation of ice caused the blockage of the engines air intake assembly,
- Following impact with trees, the aircraft lost parts and the running engine n°2 caused the fire.